Body-Focused Repetitive Behaviors (BFRBs): Susceptability and Triggers

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By: Shannon Bussnick, LSW

Body-focused repetitive behaviors (BFRBs) refer to habitual actions that involve repeated self-grooming activities like hair-pulling, skin-picking, or nail-biting. These behaviors, often considered a form of stress relief, exist on a spectrum ranging from harmless habits to compulsive actions that can cause physical and emotional harm.

In recent years, awareness of BFRBs has grown, for myself as well, with more individuals sharing their personal experiences with BFRBs, leading to a deeper understanding of their connection to mental health and developmental conditions.

In this blog, we’ll explore who BFRBs affect, how they relate to mental health conditions, when treatment is necessary, and the factors that may cause someone to be more prone to developing a BFRB.

Who Do BFRBs Affect?

BFRBs can affect people of all ages, from children to adults. However, body-focused repetitive behaviors are most commonly seen in adolescents and young adults. While BFRBs can appear in anyone, they are often associated with specific mental health or developmental conditions, as we’ll discuss below.

Conditions Commonly Tied to BFRBs:

• Obsessive-Compulsive Disorder (OCD): BFRBs are sometimes linked to OCD-related behaviors, where individuals may repetitively engage in actions like hair-pulling to alleviate anxiety.
• Anxiety Disorders: BFRBs and anxiety often go hand-in-hand. Stress triggers actions like skin-picking or nail-biting, offering temporary relief.
• Autism Spectrum Disorder (ASD): Individuals with ASD and BFRBs might engage in stimming behaviors such as repetitive movements to manage sensory overload.
• Attention-Deficit/Hyperactivity Disorder (ADHD): Impulsivity and restlessness in individuals with ADHD can contribute to repetitive actions like skin-picking or hair-pulling.
• Body Dysmorphic Disorder (BDD): Those with BDD may engage in skin-picking or excessive grooming to “fix” perceived flaws.

Who Is More Prone to Developing a BFRB?

While anyone can develop a BFRB, certain factors may increase the likelihood. People with the following risk factors are more prone to developing these behaviors:

• Genetics: Research suggests that BFRBs may have a genetic component. Individuals with a family history of BFRBs, OCD, or other anxiety-related disorders may be more likely to develop these behaviors themselves.
• Early Childhood Experiences: Traumatic or stressful experiences during childhood can lead to the development of BFRBs. In some cases, BFRBs emerge as a coping mechanism to manage unresolved emotions or feelings of anxiety.
• Co-occurring Mental Health Conditions: As mentioned earlier, those with anxiety disorders, OCD, ADHD, or autism spectrum disorder are at a higher risk of developing BFRBs. These conditions often involve difficulties with impulse control or emotional regulation, which may contribute to the repetitive behaviors.
• Female Gender: Studies have shown that women are more likely to develop certain types of BFRBs, such as trichotillomania and dermatillomania. While the reasons for this gender difference are not fully understood, it may be related to societal pressures or differences in how men and women process stress and emotions.
• Perfectionism or High Expectations: Individuals who place significant pressure on themselves to meet high standards may develop BFRBs as a response to stress or frustration when they feel they are falling short of their own expectations.
• Sensory Sensitivities: For individuals with autism spectrum disorder or sensory processing issues, sensory overload or understimulation can lead to the development of Body-Focused Repetitive Behaviors (BFRBs) as a way to manage these sensitivities. Highly sensitive persons (HSPs) are also prone to adopting BFRBs as a coping mechanism for their enhanced perception and emotional flooding.

BFRBs on a Spectrum: From Habit to Compulsion

BFRBs exist on a spectrum, from minor habits like occasional nail-biting to more severe cases, such as compulsive hair-pulling that can lead to noticeable bald patches and even infections. The severity of the behavior doesn’t always correlate with the level of distress it causes, though. For instance, someone may experience minor skin-picking without major concern, while others might be more impacted by the emotional and social consequences.

Common Triggers for BFRBs

Triggers for body-focused repetitive behaviors can vary significantly.

Some common triggers include:

• Stress and Anxiety: Many individuals with BFRBs and stress find relief in repetitive actions during periods of high tension.
• Boredom or Restlessness: A lack of mental engagement can trigger actions like nail-biting or hair-twirling.
• Sensory Needs: Especially for individuals with autism, BFRBs can fulfill sensory needs and serve as a form of self-stimulation.
• Emotional Distress: Sadness, guilt, or frustration can cause someone to turn to repetitive grooming behaviors as a way to cope.

When to Seek Treatment for BFRBs

Not all BFRBs require treatment. In fact, some can serve as effective coping mechanisms for stress or sensory relief. However, intervention may be necessary when:

• The behavior causes physical harm, such as skin infections or scarring.
• BFRBs interfere with social or occupational functioning.
• The individual feels a loss of control over the behavior and experiences distress.

Treatment Approaches for Body-Focused Repetitive Behaviors

Treatment for BFRBs can vary based on the individual and the severity of their behavior. Several approaches have been shown to be effective:

• Cognitive Behavioral Therapy (CBT): One of the most common treatments, CBT for BFRBs, focuses on identifying and altering the thoughts and actions that trigger repetitive behaviors. Habit Reversal Training (HRT) is a specific form of CBT designed to help people replace their BFRBs with healthier actions.
• Mindfulness and Relaxation Techniques: Mindfulness-based stress reduction (MBSR) can help individuals become more aware of their behaviors and manage stress without resorting to BFRBs.
• Medication: In some cases, medications like Selective Serotonin Reuptake Inhibitors (SSRIs) may be prescribed to treat underlying conditions like anxiety or OCD that contribute to BFRBs. Medications address the emotional triggers rather than the behavior itself, potentially reducing the urge to engage in repetitive actions.

When Self-Soothing Behaviors Should Be Allowed

Sometimes, it’s best to allow BFRBs to manifest, particularly when they serve as self-soothing mechanisms for stress or sensory regulation.

For example, mild hair-twirling or nail-biting may not pose any significant harm and could provide emotional relief. However, it’s crucial to monitor when behaviors cross the line from self-soothing to self-harming.

A Shift in Understanding: Beyond Bad Habits

Historically, body-focused repetitive behaviors were labeled as “bad habits,” often met with attempts to stop them through punishment or willpower. However, our understanding of BFRBs and mental health has shifted over time. Rather than viewing these actions solely as problems to be fixed, we now recognize that BFRBs can be complex coping mechanisms tied to deeper emotional needs or developmental conditions.

Research into BFRBs has increased in recent decades, particularly as awareness of OCD, anxiety disorders, and autism spectrum disorder has grown.

Conclusion

Body-focused repetitive behaviors are multifaceted and should not be dismissed as simple bad habits. Whether serving as a form of stress relief or signaling a deeper psychological need, BFRBs exist on a spectrum that ranges from minor habits to behaviors that interfere with daily life. Recognizing when these behaviors are harmful—and when they serve a beneficial purpose—can help individuals navigate their unique journey to mental well-being.

If BFRBs are causing physical harm or distress, there is help available. Treatment options like CBT, HRT, and medication can provide relief and explore the root of behavior. Ultimately, understanding the root causes of these behaviors allows us to move beyond judgment and welcome a more supportive, informed perspective.

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References:

1. Grant, J. E., & Odlaug, B. L. (2009). Understanding and Treating Body-Focused Repetitive Behaviors. Cognitive and Behavioral Practice.
2. Woods, D. W., et al. (2006). The Treatment of Habit Reversal in Body-Focused Repetitive Behaviors. Journal of Consulting and Clinical Psychology.
3. American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
4. Franklin, M. E., & Tolin, D. F. (2007). Habit Reversal Training and Cognitive-Behavioral Therapy for Trichotillomania. Behavior Therapy.

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